BackgroundThe CEASE (Clinical Effort Against Secondhand Smoke Exposure) intervention was developed to help pediatricians routinely and effectively address the harms of family smoking behaviors. Based on paper versions of CEASE, we partnered with the American Academy of Pediatrics’ online education department and developed a completely distance-based training, including an online CME training, handouts and education materials for families, and phone and email support.MethodsThe pediatric offices of two low income health clinics with primarily Medicaid populations were selected for the study. Pre and post intervention data by survey of the parents was collected in both practices (Practice 1 n = 470; Practice 2 n = 177). The primary outcome for this study was a comparison of rates of clinician’s asking and advising parents about smoking and smoke-free home and cars.ResultsExit surveys of parents revealed statistically significant increases in rates of clinicians asking about parental smoking (22% vs. 41%), smoke-free rules (25% vs. 44%), and asking about other smoking household members (26% vs. 48%).ConclusionsThrough a completely distance based intervention, we were able to train pediatricians who see low income children to ask parents about smoking, smoke-free home and car rules, and whether other household members smoke. Implementing a system to routinely ask about family tobacco use and smoke-free home and car rules is a first step to effectively addressing tobacco in a pediatric office setting. By knowing which family members use tobacco, pediatricians can take the next steps to help families become completely tobacco-free.Trial registrationClinical trials number: NCT01087177

WHAT'S KNOWN ON THIS SUBJECT: Tobacco smoke exposure is associated with increased morbidity in children, and exposure in cars can be particularly intense. The American Academy of Pediatrics policy statement recommends that pediatricians assist families in adopting smoke-free car policies. WHAT THIS STUDY ADDS:In this study, few smoking parents had a strictly enforced smoke-free car policy. Low rates of pediatric health care providers addressing smoking in the car highlights the need for improved pediatric interventions to protect children from tobacco smoke toxins. abstract OBJECTIVE: To determine prevalence and factors associated with strictly enforced smoke-free car policies among smoking parents. METHODS:As part of a cluster, randomized controlled trial addressing parental smoking, exit interviews were conducted with parents whose children were seen in 10 control pediatric practices. Parents who smoked were asked about smoking behaviors in their car and receipt of smoke-free car advice at the visit. Parents were considered to have a "strictly enforced smoke-free car policy" if they reported having a smoke-free car policy and nobody had smoked in their car within the past 3 months. RESULTS:Of 981 smoking parents, 817 (83%) had a car; of these, 795 parents answered questions about their car smoking policy. Of these 795 parents, 29% reported having a smoke-free car policy, and 24% had a strictly enforced smoke-free car policy. Of the 562 parents without a smoke-free car policy, 48% reported that smoking occurred with children present. Few parents who smoke (12%) were advised to have a smoke-free car. Multivariable logistic regression controlling for parent age, gender, education, and race showed that having a younger child and smoking #10 cigarettes per day were associated with having a strictly enforced smoke-free car policy. CONCLUSIONS:The majority of smoking parents exposed their children to tobacco smoke in cars. Coupled with the finding of low rates of pediatricians addressing smoking in cars, this study highlights the need for improved pediatric interventions, public health campaigns, and policies regarding smoke-free car laws to protect children from tobacco smoke.

Each year 40% of the world's children are exposed to tobacco smoke and 166,000 children die from that exposure annually. The 2006 and 2010 U.S. Surgeon General Reports concluded that there is no safe level of tobacco smoke exposure (TSE). The only way to completely protect children from the dangers of household TSE is to help all household members quit. Due to the many health concerns associated with children's TSE, parental tobacco control is a priority within the pediatric setting. Child healthcare clinicians are in a unique position to influence the smoking behaviors of parents, thereby improving the health of their patients. The Clinical and Community Effort Against Secondhand Smoke Exposure (CEASE) is a parental tobacco control intervention that uses an operational form of the U.S. Department of Health and Human Service's (HHS) Treating Tobacco Use and Dependence Guideline in the context of the child's outpatient medical visit. The CEASE method includes three steps (Ask, Assist, Refer) that encompass the goals of the 5A's (Ask, Advise, Assess, Assist, Arrange) in a simplified format, allowing for brief, tailored cessation support for the person who smokes. This paper summarizes the research on the harms of TSE and explores how child healthcare clinicians can most effectively eliminate these health risks to children by implementing CEASE. Finally, we look at legislative initiatives that clinicians can support to help protect children from the harms of TSE.

BackgroundRole conflict can motivate behavior change. No prior studies have explored the association between parent/smoker role conflict and readiness to quit. The objective of the study is to assess the association of a measure of parent/smoker role conflict with other parent and child characteristics and to test the hypothesis that parent/smoker role conflict is associated with a parent’s intention to quit smoking in the next 30 days. As part of a cluster randomized controlled trial to address parental smoking (Clinical Effort Against Secondhand Smoke Exposure—CEASE), research assistants completed exit interviews with 1980 parents whose children had been seen in 20 Pediatric Research in Office Settings (PROS) practices and asked a novel identity-conflict question about “how strongly you agree or disagree” with the statement, “My being a smoker gets in the way of my being a parent.” Response choices were dichotomized as “Strongly Agree” or “Agree” versus “Disagree” or “Strongly Disagree” for the analysis. Parents were also asked whether they were “seriously planning to quit smoking in 30 days.” Chi-square and logistic regression were performed to assess the association between role conflict and other parent/children characteristics. A similar strategy was used to determine whether role conflict was independently associated with intention to quit in the next 30 days.MethodsAs part of a RTC in 20 pediatric practices, exit interviews were held with smoking parents after their child’s exam. Parents who smoked were asked questions about smoking behavior, smoke-free home and car rules, and role conflict. Role conflict was assessed with the question, “Please tell me how strongly you agree or disagree with the statement: ‘My being a smoker gets in the way of my being a parent.’ (Answer choices were: “Strongly agree, Agree, Disagree, Strongly Disagree.”)ResultsOf 1980 eligible smokers identified, 1935 (97%) responded to the role-conflict question, and of those, 563 (29%) reported experiencing conflict. Factors that were significantly associated with parent/smoker role conflict in the multivariable model included: being non-Hispanic white, allowing home smoking, the child being seen that day for a sick visit, parents receiving any assistance for their smoking, and planning to quit in the next 30 days. In a separate multivariable logistic regression model, parent/smoker role conflict was independently associated with intention to quit in the next 30 days [AOR 2.25 (95% CI 1.80-2.18)].ConclusionThis study demonstrated an association between parent/smoker role conflict and readiness to quit. Interventions that increase parent/smoker role conflict might act to increase readiness to quit among parents who smoke.Trial registrationClinical trial registration number: NCT00664261.

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Hospitals are no strangers to mistakes and it is well known that errors occur regularly in United States hospitals. In understanding patient safety issues in the healthcare setting the Joint Commission determined that up to "80% of serious medical errors" relate back to communication. Nurses provide a large portion of care in hospital settings and as such are uniquely positioned to speak up when processes aren't followed or improper practices are observed with the potential to prevent errors. In light of the fact that communication is such a significant factor in medical errors, one can understand the importance of a healthcare industry where speaking up is the norm. By supporting the expectation that nurses speak up, organizations can improve patient safety. Factors such as leaders who are good role models and organizations that reward speaking up can be built upon to strengthen a hospital's culture of safety. Starting a conversation in organizations about the practice of speaking up is needed to end silence in hospitals to help prevent useless loss of function, life, and healthcare dollars.

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